Prior Authorization Requirements - Effective Jan. 1, 2021 ......2021/01/01 · obstetric physician services and 23-hour observation where prior authorization is not needed. Procedures

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PCA-1-20-00295-Clinical-WEB_03012020

© 2020 United HealthCare Services, Inc.

Prior Authorization Requirements

for Michigan Medicaid, Healthy Michigan Plan (HMP),

and Children’s Special Health Care Services (CSHCS)

Effective Jan. 1, 2021

General Information This list contains prior authorization requirements for UnitedHealthcare Community Plan in Michigan’s participating care providers for inpatient and outpatient services. To request prior authorization, please submit your request online, or by phone or fax:

• Online: Use the Prior Authorization and Notification tool on Link. Go to UHCprovider.com and click on the Link button in the top right corner. Then, select the Prior Authorization and Notification tile on your Link dashboard.

• Phone: 800-903-5253 • Fax: 855-225-9847 – A fax form is available at UHCprovider.com/MIcommunityplan > Prior Authorization and

Notif ication Resources > Prior Authorization Paper Fax Forms.

Prior authorization is not required for emergency or urgent care. Out-of-network physicians, facilities and other health care providers must request prior authorization for all procedures and services, excluding emergent or urgent care. Exceptions to this process are orthopedic physician services, medically necessary obstetric physician services and 23-hour observation where prior authorization is not needed.

Procedures and Services Additional Information CPT® or HCPCS Codes and/or How to Obtain Prior Authorization

Abortion Prior authorization is required

59840 59841 59850 59851

59852 59855 59856 59857

59866

Bariatric surgery

Bariatric surgery and specific obesity-

related services

Prior authorization is required

43644 43645 43659 43770

43775 43842 43845 43846

43847 43848 43860

Bone growth stimulator

Electronic stimulation or ultrasound to heal fractures

Prior authorization is required 20975

Breast reconstruction

(non-mastectomy)

Reconstruction of the breast except

when following mastectomy


19316 19318 19325 19328

19330 19340 19342 19350

19357 19361 19364 19367

19368 19369 19370 19371

19380 19396

Cancer supportive care

Prior authorization is required for

colony- stimulating factor drugs and

bone- modifying agents administered

in an outpatient setting for a cancer

diagnosis

*Codes J1442, J1447 J2505, Q5101,

Q5108, Q5110, Q5111 and Q5120

also require prior authorization for

non-oncology DX. See Injectable

medications section below.

Injectable colony-stimulating factor drugs

that require prior authorization:

Filgrastim (Neupogen®)

J1442*

Filgrastim-aafi (NivestymTM)

Q5110*

Filgrastim-sndz (Zarxio®)

Q5101*

Pegfilgrastim (Neulasta®)

J2505*

Pegfilgrastim-bmez (Ziextenzo®)

Q5120*

Pegfilgrastim-cbqv (UDENYCATM)

https://www.uhcprovider.com/

https://www.uhcprovider.com/en/health-plans-by-state/michigan-health-plans/mi-comm-plan-home.html?cid=none


PCA-1-20-00295-Clinical-WEB_03012020



Cancer supportive care (continued) Q5111*

Pegfilgrastim-jmdb (FulphilaTM)

Q5108*

Sargramostim (Leukine®)

J2820

Tbo-filgrastim (Granix®)

J1447*

Bone-modifying agent that requires prior

authorization:

Denosumab (Xgeva®)

J0897

For prior authorization, p lease submit requests

online by using the Prior Authorization and

Notification tool on Link. Go to

UHCprovider.com and click on the Link button in

the top right corner. Then, select the Prior

Authorization and Notification tile on your Link

dashboard. Or, call 888-397-8129.

Cardiovascular

Prior authorization is required 37220 37221 37224 37225

37226 37227 37228 37229

75710* 75716*

*Prior authorization is required for the following

diagnosis codes: E08.51 E08.52 E08.59 E08.621

E09.51 E09.52 E09.59 E09.621

E10.51 E10.52 E10.59 E10.621

E11.51 E11.52 E11.59 E11.621

E13.51 E13.52 E13.59 E13.621

I70.201 I70.202 I70.203 I70.208

I70.209 I70.211 I70.212 I70.213

I70.218 I70.219 I70.221 I70.222

I70.223 I70.228 I70.229 I70.231

I70.232 I70.233 I70.234 I70.235

I70.238 I70.239 I70.241 I70.242

I70.243 I70.244 I70.245 I70.248

I70.249 I70.25 I70.261 I70.262

I70.263 I70.268 I70.269 I70.291

I70.292 I70.293 I70.298 I70.299

I70.301 I70.302 I70.303 I70.308

I70.309 I70.311 I70.312 I70.313

I70.318 I70.319 I70.321 I70.322

I70.323 I70.329 I70.331 I70.332

I70.333 I70.334 I70.335 I70.338

I70.339 I70.341 I70.342 I70.343

I70.344 I70.345 I70.348 I70.349

I70.35 I70.361 I70.362 I70.363

I70.369 I70.391 I70.392 I70.393

I70.399 I70.401 I70.402 I70.403

I70.408 I70.409 I70.411 I70.412


PCA-1-20-00295-Clinical-WEB_03012020



Cardiovascular (continued)

I70.413 I70.418 I70.421 I70.422

I70.423 I70.428 I70.429 I70.431

I70.432 I70.433 I70.434 I70.435

I70.438 I70.439 I70.441 I70.442

I70.443 I70.444 I70.445 I70.448

I70.449 I70.461 I70.462 I70.463

I70.468 I70.469 I70.491 I70.492

I70.493 I70.498 I70.499 I70.501

I70.502 I70.503 I70.508 I70.509

I70.511 I70.512 I70.513 I70.518

I70.519 I70.521 I70.522 I70.523

I70.528 I70.529 I70.531 I70.532

I70.533 I70.534 I70.535 I70.538

I70.539 I70.541 I70.542 I70.543

I70.544 I70.545 I70.548 I70.549

I70.561 I70.562 I70.563 I70.568

I70.569 I70.591 I70.592 I70.593

I70.598 I70.599 I70.601 I70.602

I70.603 I70.608 I70.609 I70.611

I70.612 I70.613 I70.618 I70.619

I70.621 I70.622 I70.623 I70.628

I70.629 I70.631 I70.632 I70.633

I70.634 I70.635 I70.638 I70.639

I70.641 I70.642 I70.643 I70.644

I70.645 I70.648 I70.649 I70.661

I70.662 I70.663 I70.668 I70.669

I70.691 I70.692 I70.693 I70.698

I70.699 I70.701 I70.702 I70.703

I70.708 I70.709 I70.711 I70.712

I70.713 I70.718 I70.719 I70.721

I70.722 I70.723 I70.728 I70.729

I70.731 I70.732 I70.733 I70.734

I70.735 I70.738 I70.739 I70.741

I70.742 I70.743 I70.744 I70.745

I70.748 I70.749 I70.761 I70.762

I70.763 I70.768 I70.769 I70.791

I70.792 I70.793 I70.798 I70.799

I70.8 I70.90 I70.91 I70.92

I72.3 I72.4 I72.8 I72.9

I73.89 I73.9 I74.3 I74.4

I74.5 I74.8 I74.9 I75.021

I75.022 I75.023 I75.029 I75.89

I77.1 I77.2 I77.70 I77.72

I77.77 I77.79 I96 L03.115

L03.116 L97.319 L97.329 L97.419

L97.429 L97.511 L97.512 L97.513

L97.519 L97.521 L97.522 L97.529

L97.819 L97.828 L97.829 L97.909

L97.919 L97.929 L98.491 L98.499


PCA-1-20-00295-Clinical-WEB_03012020



Cardiovascular (continued) M79.604 M79.605 M79.606 M79.609

M79.651 M79.652 M79.659 M79.661

M79.662 M79.669 M79.671 M79.672

M79.673 M79.674 M79.675 M79.676

M86.661 M86.662 M86.669 M86.671

M86.672 M86.679 M86.8X7 Q27.30

Q27.32 Q27.39 Q27.8 Q27.9

Q87.2 R93.6 S35.511A S35.512A

S81.801A S81.802A S81.809A S91.301A

S91.302A S91.309A T82.312A T82.318A

T82.319A T82.338A T82.392A T82.398A

T82.399A T82.818A T82.856A T82.858A

T82.868A T82.898A Z95.820 Z98.62

Centers for Medicare & Medicaid Services (CMS) inpatient only

procedures

Services determined by CMS to be inpatient only must be requested as

inpatient. If performed as outpatient

procedures, they’re not payable

according to CMS Outpatient

Prospective Payment System

guidelines.

For a list of inpatient only codes,

please visit CMS.gov > Medicare >

Medicare Fee for Service Payment >

Hospital Outpatient PPS > Addendum

A and Addendum B Updates >

Addendum B (most recent copy) >

Status Indicator (SI) C in column D.

Chemotherapy


injectable chemotherapy drugs

administered in an outpatient setting including intravenous, intravesical

and intrathecal for a cancer diagnosis

Injectable chemotherapy drugs that require

prior authorization:

• Chemotherapy injectable drugs (J9000 - J9999), Leucovorin (J0640), Levoleucovorin

(J0641, J0642)

• Chemotherapy injectable drugs that have a

Q code

• Chemotherapy injectable drugs that have not

yet received an assigned code and will be

billed under a miscellaneous Healthcare

Common Procedure Coding System (HCPCS)

code

Please submit prior authorization requests

online by using the Prior Authorization and


UHCprovider.com and click on the Link button

in the top right corner. Then, select the Prior

Authorization and Notification tile on your Link


Cochlear implants and other auditory implants

A medical device within the inner ear

with an external portion that helps

persons with profound sensorineural

deafness achieve conversational

speech


69710 69714 69715 69718

69930 L8619 L8691 L8692


PCA-1-20-00295-Clinical-WEB_03012020



Cosmetic and reconstructive

Cosmetic procedures that change or

improve physical appearance without

significantly improving or restoring

physiological function

Reconstructive procedures that treat a

medical condition or improve or

restore physiologic function


11960 11971 15820 15821

15822 15823 15830 15847

17106 17107 17108 17999

21137 21138 21139 21172

21175 21179 21180 21181

21182 21183 21184 21230

21235 21256 21275 21280

21282 21295 21740 21742

21743 28344 30620 67900

67901 67902 67903 67904

67906 67908 67909 67911

67912 67914 67915 67916

67917 67921 67922 67923

67924 67950 67961 67966

Q2026

Durable medical equipment (DME)

Prior authorization is required only for

the codes listed with a retail purchase

or cumulative rental cost of more than

$500

Prosthetics are not DME – see

Orthotics and prosthetics.

Some home health care services

may qualify but are not subject to

the cost threshold – see Home

health care.

*J&B Medical Supply Co, Inc. is the

preferred vendor for E0784. To reach

J&B Medical Supply, please call 800-

737-0045.

A9900 E0194 E0265 E0266

E0277 E0328 E0329 E0445

E0457 E0460 E0465 E0466

E0470 E0471 E0483 E0636

E0637 E0638 E0641 E0642

E0652 E0656 E0669 E0670

E0700 E0710 E0766 E0784*

E0787 E0984 E0986 E1002

E1003 E1004 E1005 E1006

E1007 E1008 E1009 E1010

E1030 E1161 E1229 E1231

E1232 E1233 E1234 E1235

E1236 E1237 E1238 E1239

E2100 E2230 E2300 E2301

E2310 E2311 E2325 E2327

E2329 E2331 E2351 E2373

E2510 E2511 E2512 E2599

E2626 E8000 E8001 K0005

K0108 K0812 K0830 K0831

K0848 K0849 K0850 K0851

K0852 K0853 K0854 K0855

K0856 K0857 K0858 K0859

K0860 K0861 K0862 K0863

K0864 K0868 K0869 K0870

K0871 K0877 K0878 K0879

K0880 K0884 K0885 K0886

K0890 K0891 S1040 V5274

Durable medical equipment (DME) –

catheter supplies

Catheter supplies are a benefit only

when provided through J&B Medical

Supply Co, Inc.

To request catheter supplies, please call J&B

Medical Supply at 800-737-0045.


PCA-1-20-00295-Clinical-WEB_03012020




diabetic supplies to include external

insulin pumps

J&B Medical Supply Co, Inc. is the

preferred vendor for diabetic supplies

and external insulin pumps.

To request diabetic supplies, please call J&B



electric breast pumps

J&B Medical Supply Co, Inc. is the

preferred vendor for electric breast

pumps.

To request electric breast pumps, please call J&B


Durable medical equipment (DME) – incontinence supplies

Incontinence supplies are a benefit only when provided through J&B

Medical Supply Co, Inc.

To request incontinence supplies, please call J&B Medical Supply at 800-737-0045.

Enteral services

In-home nutritional therapy, either

enteral or through a gastrostomy tube

Prior authorization is required B4034 B4035 B4036 B4102

B4149 B4150 B4152 B4153

B4155 B4158 B4159 B4160

B4161 B9002 B9998

Experimental and investigational

(and/or linked services)


66180 0191T S2102

Femoroacetabular impingement

syndrome (FAI)

Prior authorization is required 29914 29915 29916

Functional endoscopic sinus

surgery (FESS)


31256 31257 31259 31267

31276 31287 31288

Genetic and molecular testing to

include BRCA gene testing


genetic and molecular testing

performed in an outpatient setting

Care providers requesting laboratory

testing will be required to complete

the prior authorization/notification

process, which includes indicating the

laboratory and test name. Payment

will be authorized for those CPT

codes registered with the Genetic

and Molecular Testing Prior

Authorization/Notification program for

each specified genetic test.

Notification/Prior authorization is

required for BRCA testing before

DNA sequencing is performed. The

ordering care provider must notify the

laboratory conducting the test and the

laboratory will notify

UnitedHealthcare.

81105 81106 81107 81108

81109 81110 81111 81120

81121 81161 81162 81163

81164 81165 81166 81167

81170 81171 81172 81173

81174 81177 81178 81179

81180 81181 81182 81183

81184 81185 81186 81187

81188 81189 81190 81200

81201 81202 81203 81204

81205 81206 81207 81208

81209 81210 81212 81215

81216 81217 81218 81219

81222 81223 81225 81226

81228 81229 81233 81234

81235 81236 81237 81239

81240 81241 81242 81243

81244 81245 81250 81251

81255 81256 81257 81261

81262 81263 81264 81265

81266 81267 81268 81270

81271 81272 81273 81274

81275 81276 81284 81285

81286 81289 81290 81292

81293 81294 81295 81296

81297 81298 81299 81300

81301 81305 81306 81310


PCA-1-20-00295-Clinical-WEB_03012020



Genetic and molecular testing to

include BRCA gene testing

(continued)

81311 81312 81314 81315

81316 81317 81318 81319

81320 81321 81322 81323

81327 81329 81330 81331

81332 81333 81336 81337

81340 81341 81342 81343

81344 81345 81370 81371

81372 81373 81374 81375

81376 81377 81378 81379

81380 81381 81382 81383

81400 81401 81402 81403

81404 81405 81406 81407

81408 81420 81479 81518

81519 81599 87481 87482

87505 87506 87507 87510

87511 87512 87623 87797

87798 87799 87800 87801

0040U 0046U 0049U 0055U

0060U 0068U 0097U 0111U

0129U 0136U 0137U

Home health care Prior authorization is required

Services rendered by a Home Health

Agency. Bill type 03xx

All Michigan Medicaid allowable codes including

but not limited to the following:

G0300 G0493 G0494 G0495

G0496

In-home services


Includes all professional and/or

ancillary services performed in a

home setting, with the exception of

DME (refer to the DME section

above) and sleep studies

All Michigan Medicaid allowable codes

Injectable medications

Prior authorization is required Actemra®

J3262

Acthar®

J0800

Adakveo®

J0791

AvsolaTM

Q5121

Benlysta

J0490

Berinert®

J0597

Botulinum toxins

J0585 J0586 J0587 J0588

Brineura™

J0567


PCA-1-20-00295-Clinical-WEB_03012020



Injectable medications (continued)

Cerezyme®

J1786

Cimzia®*

J0717

Cinqair®

J2786

Cinryze®

J0598

Cryvista®

J0584

Elelyso™

J3060

Entyvio®

J3380

Erythropoiesis Stimulating Agents*****

J0885

Evenity™

J3111

Fasenra™

J0517

Feraheme®

Q0138

Gamifant®

J9210

Givlaari®

J0223

Ilaris®

J0638

Ilumya™

J3245

Inflectra®

Q5103

Injectafer®

J1439

IVIG

90283 90284 J1459 J1555

J1556 J1557 J1559 J1561

J1566 J1568 J1569 J1572

J1575 J1599

Kalbitor®

J1290

Lemtrada®

J0202

Makena®

J1726 J1729 J2675

Nucala®


PCA-1-20-00295-Clinical-WEB_03012020



Injectable medications (continued)

J2182

Ocrevus™

J2350

Onpattro™

J0222

Orencia®

J0129

Parsabiv™

J0606

Radicava®

J1301

Reblozyl®

J0896

Remicade®

J1745

Renflexis®

Q5104

Rituxan®

J9312

Rituxan Hycela®

J9311

Ruconest®

J0596

Ruxience®

Q5119

Simponi Aria®

J1602

Sodium Hyaluronate

J7320 J7321 J7322 J7324

J7325 J7326 J7327 J7329

J7331 J7332 J7333

Soliris®

J1300

Stelara®

J3358

Synagis®*

90378

Tepezza®

J3241

Therapeutic radiopharmaceuticals**

A9513 A9590 A9606 A9699

Trogarzo™

J1746

Truxima®

Q5115

Ultomiris™


PCA-1-20-00295-Clinical-WEB_03012020



Injectable medications (continued) J1303

Unclassified codes****

C9399 J3490 J3590

White blood cell colony stimulating

factors***

J1442 J1447 J2505 Q5101

Q5108 Q5110 Q5111 Q5120

Xembify®

J1558

Xolair®*

J2357

Please check our Review at Launch for New to

Market Medications policy for the most up-to-date

information on drugs newly approved by the Food

& Drug Administration (FDA) and included on our

Review at Launch Medication List. Pre-

determination is highly recommended for the

drugs on the list. The Review at Launch for New

to Market Medications policy is available at

UHCprovider.com > Menu > Policies and

Protocols > Community Plan Policies > Medical &

Drug Policies and Coverage Determination

Guidelines for Community Plan.

*Please obtain prior notification for Cimzia,

Synagis and Xolair through OptumRx prior

notifications services at 800-310-6826.

**For prior authorization, please submit requests online by using the Prior Authorization and


UHCprovider.com and click on the Link button in

the top right corner. Then, select the Prior

Authorization and Notification tool on your Link


***For codes J1442, J1447 J2505, Q5101,

Q5108, Q5110, Q5111 and Q5120, White blood

cell colony stimulating factors, prior authorization

is required for both oncology and non-oncology

DX.

For oncology DX please see Cancer supportive

care section above.

For non-oncology DX submit online at

UHCProvider.com>link>Prior Authorization and

Notification tool on your link dashboard or call 877-842-3210

****For Temporary and unclassified codes

C9061, C9399, J3490 and J3590, prior

authorization is only required for Cutaquig® and

Nyvepria™

***** For code J0885 prior authorization is

required for both oncology and non-oncology DX.

Prior authorization is not required for ESRD

diagnosis

Joint replacement

Joint, total hip and knee replacement


24360 24361 24362 24363

24370 24371 27120 27122

27125 27130 27132 27134


PCA-1-20-00295-Clinical-WEB_03012020



Joint replacement (continued)

27137 27138 27412 27446

27447 27486 27487 29866

29867 29868

Non-emergent ambulance transport Prior authorization is required A0430 A0431 A0435 A0436

Orthognathic surgery

Treatment of maxillofacial/jaw

functional impairment


21121 21123 21125 21127

21141 21142 21143 21145

21146 21147 21150 21151

21154 21155 21159 21160

21188 21193 21194 21195

21196 21198 21199 21206

21208 21209 21210 21215

21240 21242 21244 21245

21246 21247 21248 21249

21255 21296 21299

Orthotics and prosthetics

Prior authorization is required only for

orthotics and prosthetic codes listed

with a retail purchase or cumulative

rental cost of more than $500

L0112 L0170 L0456 L0462

L0464 L0480 L0482 L0484

L0486 L0624 L0629 L0631

L0632 L0634 L0636 L0637

L0638 L0640 L0700 L0710

L1000 L1005 L1200 L1300

L1499 L1680 L1700 L1710

L1720 L1730 L1755 L1820

L1832 L1834 L1840 L1844

L1845 L1846 L1860 L1945

L1950 L1970 L2000 L2010

L2020 L2030 L2034 L2036

L2037 L2038 L2060 L2106

L2108 L2136 L2350 L2510

L2627 L2628 L3230 L3265

L3649 L3674 L3720 L3730

L3740 L3900 L3904 L3999

L4000 L4010 L4020 L4631

L5010 L5020 L5050 L5060

L5100 L5105 L5150 L5160

L5200 L5210 L5220 L5230

L5250 L5270 L5280 L5301

L5312 L5321 L5331 L5341

L5500 L5505 L5510 L5520

L5530 L5535 L5540 L5560

L5570 L5580 L5590 L5595

L5600 L5610 L5613 L5616

L5639 L5640 L5642 L5644

L5646 L5648 L5653 L5673

L5682 L5683 L5700 L5702

L5703 L5705 L5706 L5716

L5718 L5722 L5724 L5726

L5728 L5780 L5812 L5816

L5818 L5822 L5824 L5828

L5830 L5845 L5962 L5964


PCA-1-20-00295-Clinical-WEB_03012020



Orthotics and prosthetics

(continued)

L5966 L5976 L5979 L5980

L5981 L5982 L5984 L5990

L5999 L6000 L6010 L6020

L6050 L6100 L6110 L6120

L6130 L6200 L6250 L6300

L6350 L6400 L6450 L6500

L6550 L6570 L6623 L6646

L6692 L6693 L6694 L6695

L6696 L6697 L6707 L6708

L6709 L6711 L6712 L6713

L6714 L6881 L6883 L6884

L6885 L6895 L6935 L7186

L8499

Outpatient Therapy • Prior Authorization is

required for any services

above and beyond the

benefit maximum

o 144 units per

calendar year for

Physical therapy

o 144 units per

calendar year for

Occupational

therapy

o 36 visits for Speech

therapies per calendar year

• Providers may call or fax:

o Phone: 800-903-

5253

o Fax: 855-225-9847

• Speech therapy is not a

covered benefit if being

provided to meet developmental milestones

Proton beam therapy

Focused radiation therapy using

beams of protons, which are tiny

particles with a positive charge


77520 77522 77523 77525

Rhinoplasty and septoplasty

Treatment of nasal functional

impairment and septal deviation


30400 30410 30420 30430

30435 30450 30460 30462

30465

Sinuplasty Prior authorization is required 31295 31296 31297 31298

Site of service (SOS) – outpatient

hospital

Prior authorization is only required

when requesting service in an

outpatient hospital setting

Prior authorization is not required if performed at a participating

Ambulatory Surgery Center (ASC)

Auditory System

69205

Cardiovascular System

36590 36832

Carpal Tunnel Surgery

64721

Cataract Surgery

66821 66982 66984 66987


PCA-1-20-00295-Clinical-WEB_03012020




hospital (continued)

66988

Colonoscopy

45378 45380 45384 45385

Cosmetic & Reconstructive

13101 13132 14040 14060

14301 21552 21931

Digestive System

42415 42440 43200 43236

43237 43238 43242 43245

43246 43247 43248 43251

43254 43255 43259 44360

44361 45171 45334 45335

45381 45390 45990 46020

46040 46050 46200 46220

46221 46250 46255 46261

46270 46275 46288 46505

46750 46910 46946

ENT Procedures

21320 30140 30520 69436

69631

Eye and Ocular Adnexa

65710 65820 66250 66710

66711 66825 66986 67010

67041 67042 67105 67108

67113 67840 68110 68115

68320 68720 68815

Female Genital System

57240 57250 57461 57520

58561 58562

Gynecologic Procedures

57522 58353 58558 58563

58565

Hemic and Lymphatic Systems

38500 38510 38525

Hernia Repair

49505 49585 49587 49650

49651 49652 49653 49654

49655

Integumentary System

10121 11440 11450 11624

11770 13121 15100 15120

15240 19020 19120 19125

Liver Biopsy

47000


PCA-1-20-00295-Clinical-WEB_03012020




hospital (continued)

Male Genital System

54840

Miscellaneous

20680

Musculoskeletal System

20552 20553 21012 21013

21336 21554 21555 21556

21930 22514 22902 22903

23071 23075 24071 27327

27337 27632 28035 28039

28041 28060 28080 28090

28104 28110 28118 28119

28124 28285 28289 28292

28296 28297 28298 28299

29806 29807 29819 29822

29823 29824 29825 29826

29827 29828 29835 29840

29845 29846 29848 29861

29875 29876 29877 29879

29880 29881 29882 29888

29893 G0260

Nervous System

64561 64640

Ophthalmologic

65426 65730 65855 66170

66761 67028 67036 67040

67228 67311 67312

Respiratory System

30802 30930 31525 31535

31536 31541 31624

Tonsillectomy & Adenoidectomy

42820 42821 42825 42826

42830

Upper Gastrointestinal Endoscopy

43235 43239 43249

Urinary System

52276 52287 52320 52344

Urologic Procedures

50590 52000 52005 52204

52224 52234 52235 52260

52281 52310 52332 52351

52352 52353 52356 54161

55040 55700 57288


PCA-1-20-00295-Clinical-WEB_03012020



Sleep apnea procedures and

surgeries

Maxillomandibular advancement and

oral-pharyngeal tissue reduction for

treating obstructive sleep apnea


21685 41599 42145

Spinal surgery


22100 22101 22102 22110

22112 22114 22206 22207

22210 22212 22214 22220

22224 22532 22533 22548

22551 22554 22556 22558

22586 22590 22595 22600

22610 22612 22630 22633

22800 22802 22804 22808

22810 22812 22818 22819

22830 22849 22850 22852

22855 22856 22861 22864

22865 22899 63001 63003

63005 63011 63012 63015

63016 63017 63020 63030

63040 63042 63045 63046

63047 63050 63055 63056

63064 63075 63077 63081

63085 63087 63090 63101

63102 63170 63172 63173

63185 63190 63191 63194

63195 63196 63198 63199

63200 63250 63251 63252

63265 63267 63268 63270

63271 63272 63286 63300

63301 63302 63303 63304

63305 63306 63307 63308

Stimulators

Implantation of a device that sends

electrical impulses

Prior authorization is required Bone growth stimulator

E0747 E0748 E0760

Neurostimulator

43648 43881 43882 61863

61864 61867 61868 61885

61886 63650 63655 63685

64555 64568 64570 64590

Transplants

Prior authorization is required For transplant and CAR T-cell therapy services

including Kymriah™ (tisagenlecleucel) and

Yescarta™ (axicabtagene ciloleucel), please call

the UnitedHealthcare Community and State

Transplant Case Management team at

800-418-4994 or the notification number on the

back of the member’s health plan ID card.

32850 32851 32852 32853

32854 32855 32856 33930


PCA-1-20-00295-Clinical-WEB_03012020



Transplants (continued) 33933 33935 33940 33944

33945 38208 38209 38210

38212 38213 38214 38215

38232* 38240 38241 38242

44132 44133 44135 44136

44137 44715 44720 44721

47133 47135 47140 47141

47142 47143 47144 47145

47146 47147 48551 48552

48554 50300 50320 50323

50325 50340 50360 50365

50370 50380 50547 S2060

S2061 S2152 CAR T-cell therapy

0537T 0538T 0539T 0540T

*Code 38232 will only require prior authorization

for an oncology diagnosis

Vein procedures

Removal and ablation of the main

trunks and named branches of the

saphenous veins for treating venous

disease and varicose veins of the

extremities


36468 36473 36475 36478

37700 37718 37722 37780

Ventricular assist devices (VAD)

A mechanical pump that takes over

the function of the damaged ventricle

of the heart and restores normal blood flow

Prior authorization is required Please call the notification number on the back

of the member’s health plan ID card. Then, fax

the form provided by the nurse to the Optum

VAD Case Management team at 855-282-8929.

33927 33928 33929 33975

33976 33979 33981 33982

33983 Q0507 Q0508 Q0509

Wound vac Prior authorization is required E2402

Documents

Prior Authorization Requirements - Effective Jan. 1, 2021 ......2021/01/01 · obstetric physician services and 23-hour observation where prior authorization is not needed. Procedures